Phenobarbital

Each Project Albert mission flew from White Sands Proving Ground, and every monkey flew completely unconscious.

Uh [laughs] they were dosed up with sodium pentobarbital and a healthy dose of Luminal, which is also a, uh, barbiturate.

Hell, [laughs] all these monkeys are-

These, these guys are g- Yeah, every single monkey is flying, fucking swimming in barbs.

So it's like I empathize with what my friend is going through, but that doesn't make it not difficult for me to deal with.

Especially with this year being a year that I'm taking off of consuming cannabis, it's kind of a, you know, it's probably one of the reasons why I consumed it so much is because of the constant state of worry that i find myself in with you know situations in my personal life and you know coming out to the woods kind of helps to chill that out a little bit i do feel a little bit better now that i've gotten uh you know to doing the walking thing uh especially you know earlier today i went and visited him in the hospital and he seems a little bit more grounded you know they're giving him to kind of like keep him calm I think a mix of Valium and Phenobarbital, which are both pretty heavy drugs.

One's a benzo and one's a barbiturate.

And so those are keeping him pretty, like, grounded in reality.

What does the literature actually say about discharging patients after phenobarb treatment in the ED?

So one of the greatest challenges in interpreting the discharge evidence is that almost all the studies are retrospective in nature, and therefore, the patient characteristics surrounding the patient's alcohol withdrawal severity is not uniform.

Phenobarb dosing is highly variable, and the choice of admission versus discharge was often based on clinician discretion.

And it's due to the heterogeneity of this data and the lack of reliable safety data surrounding discharge that the GRACE4 guidelines could not recommend the use of phenobarb in patients being discharged from the emergency department based on the existing evidence.

It is important to acknowledge, however, to your point, Anton, that this is an area of clinical controversy because there are lots of centers around North America that are currently discharging these patients and many centers that automatically ensure that these patients get admitted.

Let's see.

Tippy Smith, Elixir, Phenobarbital, Tincture, Belladonna.

What's the matter, fella? Stomachache?

No, I'm okay He isn't either He just doesn't like medicine, that's all But the minute we get back on the road, he'll be miserable

So that's a lot of less lorazepam over a hospital course.

Phenobarbital use kind of appropriately increased in terms of utilization.

It was using that weight-based fixed dosing.

The maximum SIWA revised scores were reduced by 4 to 5 points between the 24 and 96-hour mark in patients treated with phenobarbital compared to benzodiazepines.

Rates of intubation, prolonged restraints, and hospital mortality remained unchanged, demonstrating like really no safety concerns between the two protocols.

So the clinical bottom line here is that at least in this kind of retrospective quality improvement study, also kind of consistent with kind of recent updates and guidelines.

Phenobarbital, it seems to kind of reign supreme here, right? It seems to have better, it's better for everyone, right? So kind of patients seem to capture quicker.

Patients have lower withdrawal severity.

And right? What a cop-out of an answer, right? But I say that in a meaningful way, that, one, hopefully it takes a little bit of the stress off of the veterinarians knowing that are there medications that have more scientific backing? Absolutely.

Phenobarbital, if you want the proven most efficacious medication, that's your drug.

There's also newer medications that don't have the same degree of research, the same degree of literature, and I think the ACVIM consensus statement on management of seizures did a great job of really summarizing all of the literature on these medications, all of the drug side effects, and talking about what we do and don't know from a literature perspective.

And I definitely encourage people, if you're interested in epilepsy, if you wanna kind of take that next deep dive into it, read that because it really does encompass kind of our, our working knowledge base of epilepsy and seizure medication thereof in our pet populations with a strong focus on dogs.